3rd

Mindanao Sanitarium & Hospital CollegeSchool of Nursing

Barangay San Miguel, Iligan City 9200Phone No.(063) 221-9219, Fax No. (063) 223-2114, mshnet@yahoo.com

Accredited By: Association of Christian Schools, Colleges and Universities Accrediting Agency, IncorporatedAccreditation Level: Level II, April 29, 2011 – April 2014

Accredited By: Adventist Accrediting AssociationAccreditation Level: Level II, October 4, 2010-December 31, 2012

SURGICAL SCRUB in: Gregorio T. Lluch Memorial Hospital, Palao, Iligan CityAdventist Medical Center, Barangay San Miguel, Iligan CityHospital/Home/Lying-in, Municipality/City/Province

Prepared by:Printed name and Signature of Student: CRISTINA L. JAYSON

Date Performed and

Time Started

Patient’s INITIAL Only

Case Number(not applicable for Birthing/Lying-in

Clinics/Homes)

SURGICAL PROCEDURE PERFORMED

O.R. Nurse on Duty(Name and Signature)

SUPERVISED BYClinical Instructor

Name and Signature

August 9, 201211:30 PM

RB147899

Appendectomy Jed R. Santos, RN, CRNPRC Number: 0660385

Valid Until: July 14, 2016

Darilyn G. Literatus, MN, RNPRC Number: 0301632

Valid Until: November 25, 2016

September 13, 201211:32 AM

SB130179

Pelvic Laparotomy Wendy Mar S. Rodrigo, RNPRC Number: 0313886

Valid Until: March 3, 2015

Sheilma Dreamy G. Manata, MN,RNPRC Number: 0173264

Valid Until: May 28, 2017

December 6, 20121:40 PM

JG062232

First Repeat Low Segment Transverse Cesarean Section

Belen Joy C. Patindol, RNPRC Number: 0306764

Valid Until: December 20, 2015

Sheilma Dreamy G. Manata,MN, RNPRC Number: 0173264

Valid Until: May 28, 2017

Noted by: EVALYN M. LECCIONES, MN, RN Approved by: G’TER G, GAID, PhD, MAN, RN N (Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D No.:0245303 Valid Until:May 9, 2015 Dean, PRC I.D. No.:0302269 Valid Until: September 13, 2015Date document is signed: ________ Time:______________ Date document is signed: Time: ____________________Please specify Highest Nursing Degree Earned: Master in Nursing Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

O.R. Form 1AO.R. SCRUB FORM

MAJOR